Dementia is a critical health care and health policy issue which promises to become even more important and costly as the population ages. Our overall goal in this study is to improve the quality of care for nursing home residents with dementia by critically examining and developing improvements to a major policy initiative -public reporting of quality information- in terms of the effects on processes and outcomes of care for nursing home residents with dementia. Nursing homes are a major site of care for persons with dementia, but the nursing home sector has been plagued with quality problems for several decades. After years of increasingly stringent regulation failed to raise quality to acceptable levels, the Centers for Medicare and Medicaid Services in 2002 launched Nursing Home Compare (NHC), a public reporting initiative that rates all Medicare- and Medicaid- certified nursing homes in the United States on selected aspects of care. Emerging evidence documents modest but positive changes in reported clinical quality as a result of NHC, and the US government continues to pour resources into this effort. However, care of demented residents is inherently different from care of non- demented residents. If report cards do not reflect aspects of quality most important to nursing home residents with dementia or emphasize outcomes that are not appropriate for them, they may not benefit from quality improvements and quality of dementia care may decline. This depends on whether facilities pursue quality improvement in response to public reporting through focused efforts directed only at the reported measures or through broad, structural changes, which is currently unknown. Despite the fact that nursing homes are a major provider of care to elderly individuals with dementia, the effects of this major policy initiative on care of persons with dementia have not been evaluated. Our first aim in this project is to examine quantitatively the effect of NHC on resident-level outcomes by dementia status, considering the appropriateness or potential inappropriateness of each reported measure for demented residents. We also consider several unreported measures of quality. Our second aim is to examine qualitatively, using semi-structured interviews with administrators and staff, how nursing home providers think of quality for their residents with dementia, the strategies that nursing homes pursue in response to public reporting, and the implications of these strategies- intended and unintended--for care of residents with dementia. These strategies may include coding changes and avoidance of high-risk residents as well as varied approaches to quality improvement. Our final aim is to evaluate several possibilities for improving the ability of public reporting to raise quality of care for residents with dementia, including additional risk-adjustment of existing measures and potential inclusion in NHC of dementia-appropriate but currently unreported measures. PUBLIC HEALTH RELEVANCE: Our overall goal in this study is to improve the quality of care for nursing home residents with dementia by critically examining and developing improvements to a major policy initiative -public reporting of quality information- in terms of the intended and unintended effects on quality of care for nursing home residents with dementia. Dementia is a critical health care and health policy issue which promises to become even more important and costly as the population ages.